Provider Demographics
NPI:1457673816
Name:PROVOST, AMIEE KRISTIN KOTA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMIEE
Middle Name:KRISTIN KOTA
Last Name:PROVOST
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CONSUMER SQ
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-6508
Mailing Address - Country:US
Mailing Address - Phone:518-561-0680
Mailing Address - Fax:518-563-3675
Practice Address - Street 1:25 CONSUMER SQ
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6508
Practice Address - Country:US
Practice Address - Phone:518-561-0680
Practice Address - Fax:518-563-3675
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050943183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist